Ultrasound showing clot attached to the wall of left ventricle. What is the treatment?

On XXXXXXX 25 I had a heart attack in Macau. I am an American, but currently live in another Chinese city, Nanyang, Henan, China, where I teach English. Unfortunately, i continue to have problems associated with my XXXXXXX attack, even though two stents we put in my LAD in Macau. I just got out of the hospital in Nanyang where I was treated with amiodarone medicine for a ventricular premature beat. My doctor said that the medicine was proving to be successful. However, while in the hospital, an ultrasound showed that I have a clot attached to the wall of my left ventricle (LVT). My doctor wants me to visit a hospital in Beijing for a second opinion to make sure that the LVT diagnosis done in Nanyang was correct. Meanwhile, my doctor told me to continue to take my regular hear attack meds, which include ticagrelor (Brilinta). My doctor told me me that there is not a definitive treatment for my problem. Is that correct? She also said that MOST people with LVT survive for many years just taking regular heart attack meds. Is that correct? She said that surgery is typically done only in an emergency situation and as a last result. Also, I fear that maybe the ticagrelor is not working and maybe I need to try a different blood thinner. Your advice would be greatly appreciated.

Brief Answer:
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Detailed Answer:
Dear Sir
1. We normally do not treat VPBs, especially by amiodarone. VPBs are treated only if they are causing symptoms and most of the time first choice is beta-blockers. We advise our patients to ignore it if they are not causing any symptoms or trouble to patient. Hence I would recommend a second opinion on this issue by a cardiologist with all your details.
2. The LVT formation usually occurs in initial few days to weeks after a heart attack. It may occur in an aneurysm (an out-pouching of LV wall) or without aneurysm. If it is without an aneurysm, we normally treat it with anti-coagulants like vitamin K antagonists (VKAs) for 3 months and reassess on Echocardiography (cardiac ultrasound). Most of these resolve by that time. The dose, monitoring and precautions associated with VKA use should be diligently followed. Ticagrelor is not a VKA. It is an anti-platelet agent but essential for patients with a cardiac stent. The patients who have aneurysm with LVT may require surgery depending upon size of aneurysm etc. In both case scenarios you must seek a second opinion, as VKA or similar drugs are given in both scenarios which are perhaps not given to you.
3. Once resolved, the LVT without aneurysm, it will require only aspirin or ticagrelor like medications for its prevention. Future prognosis will depend upon may other things and not only on LVT. Since LVT itself indicate a large area effected by heart attack, it is associated with a relatively poorer prognosis. But it is a generalized statement and may not be applicable to individual patient.
Hope this helps. Feel free to discuss further.
Sincerely
Sukhvinder

Follow-up: Ultrasound showing clot attached to the wall of left ventricle. What is the treatment? 7 hours later

You seem to suggest that a VKA can remove or dissolve a LVT clot. Is that correct? However, my reading of online literature is that a VKA, such as Warfarin, only prevents clots from forming. So, my LVT already exists and would not be affected by a VKA. .... Are you aware of any state of the art or trial drugs being used to safely remove an LVT? Also, I assume I do not have an aneurysm or I think my doctor would have told me.

Answered by Dr. Sukhvinder Singh 3 hours later

answer Id 267506; conversation id 274278

Brief Answer:
please see details.
Detailed Answer:
Respected Sir
1. You have read it correctly that VKA themselves do not dissolve existing clot. But Whenever a clot is formed in body, it is by natural process goes on dissolving (fibrinolysis) and new clot material is also continuously formed on the existing clot. The VKA will prevent any new addition to it and natural body process (trying to dissolve the clot) will have an upper hand and tend to dissolve the clot. The therapies which we normally use for active clot dissolution (thrombolytics) are not used in LV clots and are not recommended. Once the acute phase is over (usually 3 months), the clot usually gets organised and dont require any further treatment with anticoagulants. Whatever I wrote in my last answer is standard line of treatment for LVT without aneurysms, as per existing international guidelines.
2. As per the last guidelines (Dec 2012) published by "American college of Cardiology" Beside VKA no treatment is recommended for these clots. Hence nothing else can be recommended. The only risk of these clots is their migration to systemic circulation which is mainly for first 3 months. The prognostic significance has already been discussed in my last answer.
Hope this provides more insight into the issue.
Sincerely
Sukhvinder

Follow-up: Ultrasound showing clot attached to the wall of left ventricle. What is the treatment? 2 hours later

Ok, doctor. If I may ask you two more questions for clarification and then I will not bother you more. I'm not sure when my clot developed, but it apparently developed recently because my heart attack was on XXXXXXX 25 and no one at the hospital in Macau mentioned it. (I had the heart attack in Macau). Also, on August 3 in Nanyang, Henan, China, I collapsed because of low blood pressure. Doctors at a hospital here in Nanyang did an ultrasound at the time but did not mention any clot. The clot was only brought to my attention last week at another hospital in Nanyang. So, the clot may be new and I might be in the 3-month acute period that you are talking about. So, assuming again that I do not have an aneurysm, I should be taking a VKA now. Is that correct? I will talk to my cardiologist today (Monday) in Nanyang and ask her why she did not prescribe me a VKA for the LVT. My reading of the literature indicates that anti-platelets and anti-coagulants are both used to prevent clots. Maybe the doctor here believes it's preferable to only use the anti-platelets for the LVT. I also will be going to Beijing to get a second opinion about whether I even have a LVT. At that time I also will ask Beijing doctors about the VKA issue we are talking about, that is, the use of a VKA for the treatment of LVT. I plan to wait two weeks before I get those additional opinions in Beijing. Am I waiting too long to visit other doctors in Beijing for the additional opinions? I don't want to die. Thanks so much. XXXX

Answered by Dr. Sukhvinder Singh 6 hours later

answer Id 267508; conversation id 274478

Brief Answer:
please see below
Detailed Answer:
Respected Sir,
1. The likelihood of clot formation is higher early after acute heart attack, however an absolutely non-contracting area can invite clots any time. Moreover I can not assume anything on this issue. The Doctors taking care for you since XXXXXXX 2013 are in best position to speculate on that. Hence therapy/ treatment tailored to timing will be decided by them only.
2. We start VKAs as soon as we diagnose the LVT (after doing some preliminary investigations like platelet count, INR , liver functions test etc.). Their first aim is to prevent embolization or migration of clot to body parts like brain , kidneys etc.
None can say what will happen in next 15 days? This is unpredictable. My advise is to consult your cardiologist at earliest, confirm the diagnosis of LVT and if it is there & presumably recent, do start the treatment at earliest.
3. Although role of VKA in management of similar high risk situations for clot formation has become a bit controversial after introduction of dual antiplatelet therapy (DAPT){which include aspirin and ticagrelor like drugs} but in proven LV clots we still use VKA. The use of VKA with DAPT is associated with higher risk of bleeding episodes, however that is a necessary evil.
Feel free to write if there is anything else.
Sincerely
Sukhvinder